Hilda M. v. Saul

Background

Hilda M. sought judicial review under 42 U.S.C. § 405(g) of the Commissioner of Social Security’s final decision denying her claim for Disability Insurance Benefits. She alleged disability beginning April 22, 2015, based on chronic pain syndrome, left-knee osteoarthritis, lumbar radiculopathy, and facial pain syndrome. The Administrative Law Judge, or ALJ, found that she had severe impairments involving the cervical spine, lumbar spine, left knee, and chronic pain, but found that she could perform a full range of sedentary work and could return to her past work as an accounting clerk, receptionist, and data entry clerk.

The record included diagnoses and treatment for chronic pain, fibromyalgia, spinal conditions, knee problems, fatigue, sleep apnea, and mental-health symptoms. Two treating physicians diagnosed fibromyalgia, and the record included physical examinations showing multiple tender points and other symptoms. The ALJ nevertheless found that fibromyalgia was not a medically determinable impairment because there was not enough objective evidence to support it.

Arguments and Analysis

Hilda M. raised four issues: whether the ALJ properly evaluated her mental impairments, whether the ALJ properly evaluated fibromyalgia, whether the ALJ gave legally sufficient reasons for discounting her testimony, and whether the ALJ properly addressed medical-source statements.

The court rejected the challenge to the ALJ’s treatment of the mental impairments. It found that the ALJ did not err in finding depression nonsevere, and explained that any error at that stage would have been harmless because the ALJ considered the mental-health evidence when assessing residual functional capacity. Residual functional capacity means what a person can still do in a work setting despite physical or mental limitations.

The court found a significant problem with the fibromyalgia analysis. It explained that fibromyalgia may be established through appropriate medical evidence even though it generally does not have laboratory findings that confirm the diagnosis. Social Security guidance requires consideration of the physician’s examination, the applicable diagnostic criteria, and whether the diagnosis is consistent with the rest of the record. The court found no indication that the ALJ conducted that required analysis. Because the error could have affected the later evaluation of Hilda M.’s limitations and ability to work, the court could not treat it as harmless.

Disposition

The court granted Hilda M.’s motion for summary judgment, denied the Commissioner’s cross-motion for summary judgment, and remanded for further proceedings. On remand, the ALJ must: (1) consider Hilda M.’s diagnosed fibromyalgia as a medically determinable impairment at step two; (2) decide whether it is severe; and (3) analyze the impairments and limitations caused by fibromyalgia at later steps, regardless of whether it is found severe. The court did not decide whether Hilda M. is ultimately entitled to disability benefits. Because it remanded the case, the court did not decide Hilda M.’s remaining arguments, although it directed the agency to consider them during reconsideration.